We read with great interest the perspective by Gonzalez and associates regarding how to compound bevacizumab safely to minimize the risks of contamination. The article, however, overlooks a fact that seems to be lost in the bevacizumab versus ranibizumab debate: using a medication that is approved by the Food and Drug Administration (FDA) for intraocular injection avoids the need to expose patients to the added risk of a compounded, off-label agent like bevacizumab.

Although Gonzalez and associates provide a useful blueprint for compounding bevacizumab, it is unclear if this will result in fewer outbreaks down the road. It is true that bevacizumab does not blind people, but compounding the bevacizumab does add several different steps before the drug is administered and involves multiple people in different pharmacies and delivery areas—people who are not and will never be infallible. No amount of training, inspection, and regulation is going to eliminate completely the risk of human error. The article makes the point that administrating bevacizumab may be safer than administrating ranibizumab because use of the former agent avoids the need to withdraw the drug from a vial. However, if supplied according to the described method, bevacizumab still requires exchanging a cap with a needle. Moreover, to our knowledge, there have never been any outbreaks of endophthalmitis after using ranibizumab, and endophthalmitis outbreaks after compounded bevacizumab are disasters.

Although the Comparison of AMD Treatments Trials (CATT) demonstrated that bevacizumab and ranibizumab may result in similar visual outcomes, it is unclear if the risks of these agents are similar because of the need for compounding with bevacizumab, the unanswered questions regarding bevacizumab’s systemic safety notwithstanding. Unfortunately, many patients will not have the choice—for economic reasons—of using an FDA-approved agent like ranibizumab even if they may feel less than comfortable about the risks of compounding. In our opinion, this is the most troubling take home message from Gonzalez and associates’ article.